Quiz

   A 61-year-old man requires intubation in the emergency department for respiratory distress. He has a known heart murmur for 20 years and receives SBE prophylaxis. His wife reports two weeks of progressive dyspnea and weight gain, culminating in severe rest dyspnea.

On physical examination, his pulse is 104/min and regular, BP is 80/50 mm Hg. Jugular venous pressure is 5 cm H20 and the carotid artery shows a small volume. Crackles are audible in the lower two-thirds of both lung fields. There is a 1+ LV heave, normal S1 and a single S2. A grade 1/6 SEM is audible at the base and apex and an S3 is present. The skin is cool and mottled and there is no pitting edema.

Chest x-ray shows mild cardiomegaly, interstitial edema, and moderate sized bilateral effusions. The ECG shows sinus tachycardia, slow R wave progression, and down sloping ST segment depression in the lateral leads.